Would doctors routinely asking older patients about their memory improve dementia outcomes? YesBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1780 (Published 26 March 2013) Cite this as: BMJ 2013;346:f1780
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There has been much debate about the risks and benefits of screening for dementia in older patients (Rasmussen and McCartney, 2013) and the outcomes of the Alzheimer’s Society evidence reviews are keenly awaited. Although the first of the WHO criteria for effective screening programmes (Wilson and Junger, 1968) - that the condition should be an important health problem - is clearly applicable, it remains far from clear that dementia screening could meet the other nine criteria. However, the Department of Health (DH)’s nationwide ‘Find Assess Investigate Refer (FAIR)’ CQUIN (Commissioning for Quality and Innovation) has prompted hospitals across the country to devise systems to fulfil this financially incentivised requirement for dementia case-finding. In our large teaching hospital, care has been taken in developing a process that combines the DH ‘screening’ question – “Has this person been more forgetful over the past year such that it significantly interferes with daily life?” - with previously validated tools selected to maximise completion rates in a busy clinical setting. This ‘stepped’ process also included prompts to consider further investigations according to the hospitals guidelines on the care of patients with dementia and/or delirium, and the discharge summary letter informs the GP of the process outcome. The pathway may include referral to the older people’s liaison psychiatry service but, without such fuller assessment, the case-finding tool can only alert GPs if there is a concern about cognition, advising post-discharge re-assessment and possible specialist referral if appropriate.
As part of a broader evaluation of the usefulness of this dementia case-finding tool currently used in our hospital, we surveyed clinical staff potentially involved in using the tool. Overall, 29 clinicians participated in the survey: 25 doctors and 4 nurses. All 29 had heard of the tool and all but two had used the form at least once (20 filled in the form at least once a week and 7 less than once a week).
We asked respondents to rate the usefulness of the case-finding tool from a scale of not very useful to very useful on a 1-5 scale. Excluding the nurses surveyed because of their roles specifically involving these assessments, only 1/5 of the 25 doctors found it ‘quite useful’, and just under half ‘moderately useful’, although nine of them were interviewed in the emergency department where usually they only completed the form’s initial brief assessment and the DH ‘screening question’. It tended to be the more junior doctors who added positive comments such as “a useful reminder to screen for dementia and to order routine screening tests of CT head, TSH, B12 and folate,” “a good template or structure for a non-biased assessment” and “it identifies new cognitive issues.” Negative comments tended to come from more experienced medics who had concerns about the choice of cognitive assessment, the additional paperwork that added nothing to what they felt would have been done anyway, the difficulty in differentiating between dementia and delirium, and consequent reservations about whether this was an appropriate timing or setting. Although the tool in use is not intended for diagnosis, the specialist nurses also raised the issue of possible misdiagnosis.
Further evaluation of the screening tool in is progress aiming to determine its clinical validity. Meantime, our survey suggests that efforts to fulfil the ‘FAIR’ CQUIN’s requirements are at least raising awareness of dementia case-finding and serving to prompt less experienced doctors to follow good practice guidelines on the management of delirium and dementia.
Rasmussen J. Would doctors routinely asking older patients about their memory improve dementia outcomes? Yes. BMJ. 2013 Mar 26;346:f1780. doi: 10.1136/bmj.f1780.
McCartney M. Would doctors routinely asking older patients about their memory improve dementia outcomes? No. 2013 Mar 26;346:f1745. doi: 10.1136/bmj.f1745.
Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968. 22(11):473. Public Health Papers, #34.
Competing interests: No competing interests
The debate about screening for dementia rages on but there is an elephant in the room. (1) The philosophers would call it reification: the raising of an abstraction to a status of unreasonable concreteness. Dementia is a syndrome which in epidemiological studies exists on a continuum with normal aging. (2)
The early diagnosis campaign fails to take account of the diversity of experience of dementia: the younger patient devastated by and dominated by their diagnosis, the patient in angry denial whose refusal to cooperate with care puts them at risk of self-neglect, the placidly compliant patient who while not wanting to talk in terms of dementia or Alzheimer’s is content to receive help and the frail patient burdened by comorbidities for whom dementia is another one of a bewildering array of pathologies with which they have to contend.
The correlations between measures of cognition, function, behaviour and neuropathology are modified by numerous factors including premorbid intellectual attainment, mood and social milieu.(3),(4),(5) The blunt instrument of diagnosis fails to account for the subtleties of the human condition and hence the chief value of campaigns to achieve more dementia diagnoses will be raising awareness of the potential vulnerability of people with poor memories.
The next step should be improving awareness of how resilience against the travails of the aging process can be enhanced by practical social support, companionship and meaningful activities. To strengthen resilience, a diagnosis of dementia is neither necessary nor sufficient. Unless society turns a blind eye to the aging process, it should only be drug treatment and the use of legal powers under the Mental Health or Mental Capacity Acts that is predicated on a diagnosis.
(1) Rasmussen J and McCartney M. Would doctors routinely asking older patients about their memories improve dementia outcomes? BMJ 2013; 346:f1 745/780
(2) Whalley LJ. Brain aging and dementia: what makes the difference? Br J Psychiatry 2002 181: 369-371.
(3) Snowden DA. Healthy Aging and Dementia: Findings from the Nun Study. Ann Intern Med 2003; 139: 450-454.
(4) Iacono D, Markesbery WR, Gross M, Pletnikova O, Rudow G, Zandi P, et al. The Nun Study. Clinically silent AD, neuronal hypertrophy, and linguistic skills in early life. Neurology 2009;73:665-73.
(5) Archer N, Brown RG, Reeves SJ et al. Premorbid personality and psychological symptoms in probable Alzheimer’s disease. Am J Geriatr Psychiatry 2007;15: 202-213.
Competing interests: No competing interests
We must always be wary of the words ‘There is agreement that...’ in any medical or scientific article, for it usually involves a smokescreen hiding a void in the evidence. Michael Crichton had very strong words to say about this ‘evidence of consensus’ in his lecture to the California Institute of Technology in 2003: ‘I regard consensus science as an extremely pernicious development that ought to be stopped cold in its tracks. Historically, the claim of consensus has been the first refuge of scoundrels; it is a way to avoid debate by claiming that the matter is already settled. Whenever you hear the consensus of scientists agrees on something or other, reach for your wallet, because you’re being had.’1
When Dr Rasmussen argues that ‘There is agreement that early detection benefits patients,’ we should be concerned that she does not quote evidence, but instead a Department of Health report2. This is a common problem in this debate; indeed the World Alzheimer Report 2011 The Benefits of Early Diagnosis and Intervention concedes in their review of the literature that: ‘Several of the papers that we reviewed in the course of our systematic review contained statements regarding the benefits of early diagnosis. Many were unreferenced, and where references were provided these were generally to other papers making similar, non-evidence- based assertions.’3
It needs to be acknowledged that the DOH report Dr Rasmussen refers to does indeed contain evidence of the benefits of early diagnosis and intervention. However, this is not evidence for the benefits of the intervention that Dr Rasmussen is evaluating. For instance, the report quotes the benefits to patients, and the cost effectiveness of the Croydon Memory Service Model4 5. This is an excellent model that has shown benefit. However, the model involved increasing investment in a local memory service so that incident referrals from GPs were dealt with more efficiently and effectively. There was no screening or case finding in primary care, but better support in secondary care - exactly what my colleagues and I argued for when we raised concerns about the proposals for the dementia DES6, and exactly the opposite of the proposal Dr Rasmussen is endorsing.
In truth, we cannot know what the balance of benefits and harms of this proposal will be, since we lack the evidence. The proposals should have been properly piloted to answer this question prior to any decision being made on a national scale, and the only reason for not doing this is one of political expediency.
1. Barrio, J. R. Consensus science and the peer review. Molecular imaging and biology : MIB : the official publication of the Academy of Molecular Imaging 11, 293
2. Department of Health Living well with dementia: A National Dementia Strategy - dh_094051.pdf. at
3. Prince, M., Bryce, R. & Ferri, C. The benefits of early diagnosis and intervention World Alzheimer Report 2011. (2011).at
4. Banerjee, S. et al. Improving the quality of care for mild to moderate dementia: an evaluation of the Croydon Memory Service Model. 65, 782–788 (2007).
5. Banerjee, S. & Wittenberg, R. Clinical and cost effectiveness of services for early diagnosis and intervention in dementia. (2009).doi:10.1002/gps
6. Brunet, M. D. et al. There is no evidence base for proposed dementia screening. Bmj 345, e8588–e8588 (2012).
Competing interests: No competing interests